Urethral Stricture Surgery in Turkey

Urethral stricture surgery is an effective treatment approach that enables the narrowing occurring in the urinary canal to be corrected through surgical methods. This procedure aims to restore urine flow to normal, reduce symptoms, and protect kidney functions in the long term.

In answer to the question of how urethral stricture surgery is performed, the procedure is applied with techniques that vary according to the length and location of the stricture. By preferring endoscopic interventions or open surgical methods, the narrowed segment is removed or widened and the urinary tract is reconstructed.

The recovery process after urethral stricture surgery varies depending on the patient’s general health condition and the surgical technique applied. Catheter use, regular check-ups, and careful follow-up against the risk of infection play a critical role in preventing complications.

The risks and success rate of urethral stricture surgery are evaluated according to surgical experience and the characteristics of the stricture. Although there are risks such as infection, recurrence of the stricture, and bleeding, high success rates are achieved with appropriate patient selection and the correct technique.

What Is Urethral Stricture and What Kind of Change Does It Cause in Our Body?

The urinary canal may be perceived from the outside as a simple pipe system. However, when viewed in terms of its medical anatomy, it is a very complex transmission channel surrounded by a very rich vascular network and a special spongy structure called the “corpus spongiosum.” While this spongy tissue allows the canal to stretch during urination, it also provides intense nourishment (blood supply) that guarantees the moist mucosa inside always remains healthy. In men, the urethra is divided into two main parts according to its location. The part that extends along the penis and passes through the perineum is called the “anterior urethra,” while the deeper region that passes through the prostate and contains the muscular mechanism is called the “posterior urethra.” The thickness of this spongy tissue is not the same everywhere in the canal. For example, while this tissue is very thin in the canal at the tip of the penis, it is much thicker and more vascular in the bulbar region of the perineum. These anatomical features will directly affect the treatment plan depending on where the stricture is located.

Under normal conditions, when the urinary canal, which has perfect flexibility, is damaged for any reason, our body quickly sends new protein (collagen) cells there to repair this damage. However, unfortunately, this healing mechanism results in the formation of a hard and rigid tissue lacking flexibility, similar to a scar on our skin. This tissue hardening, which we medically call “spongiofibrosis,” causes not only the inside of the urinary canal to narrow but also that region to completely lose its flexibility, become hard like a stone, and adhere to the surrounding tissues.

What Are the Main Factors That Lead to the Development of Urethral Stricture?

In modern life and healthcare services, the factors that cause narrowing of the urinary canal spread across a very wide spectrum according to the risk carried by the patient or the region where they live. The most prominent causes encountered in daily life and medical processes are as follows:

• Prostate surgeries
• Insertion of a camera into the urinary tract
• Insertion of a urinary catheter
• Traffic accidents
• Falling from a height
• Severe blows to the perineum
• Sexually transmitted diseases
• Lichen sclerosus disease
• Congenital anatomical abnormalities

Among the reasons listed above, the most common cause of hospital admissions today is iatrogenic causes related to medical procedures. In particular, the insertion of thick instruments such as the resectoscope used to treat large prostates or the cameras used for diagnosis by rubbing against the urinary canal creates serious friction marks in the delicate layer inside the canal. In addition, very thick catheters that remain in the patient’s urinary tract for days after surgery may also prevent this tissue from being adequately supplied with blood, leading to cell death (ischemia) and subsequently narrowing.

Causes related to trauma arise as a result of much higher-energy accidents. Especially in severe traffic accidents resulting in fracture of the pelvis, the urethral region between the prostate and the muscle layer below it may suddenly tear or completely rupture. In the younger age group, on the other hand, perineal traumas seen mostly in the form of rapidly hitting a bicycle or motorcycle saddle or falling onto a hard bar or cover (straddle injury) cause serious strictures in the anterior urethra. On the other hand, untreated very severe or recurrent inflammations (urethritis), and especially stubborn skin diseases such as Lichen Sclerosus that completely dry and whiten the skin and mucosa of the urinary canal, may pave the way for much more complex and most difficult-to-treat urethral strictures.

With What Symptoms Does Urethral Stricture Manifest Itself in Patients?

The disease usually begins very insidiously. When the urinary canal starts to narrow slightly in the first days, the bladder muscles contract much more strongly and manage to overcome this resistance, so the patient may not feel a problem. However, as the narrowing increases over months or years, the bladder muscles become fatigued. The symptoms most frequently expressed by patients suspected of having urethral stricture are as follows:

• Weak urine flow
• Split urination
• Dribbling urination
• Difficulty starting urination (need to strain)
• Frequent need to go to the toilet
• Feeling of not being able to empty the bladder completely
• Waking up at night to urinate
• Recurrent urinary tract infections
• Testicular and kidney pain

These complaints greatly destroy the patient’s daily life comfort. The patient has to make a serious effort at every toilet visit, the time spent in the toilet gets longer, and the feeling of “I’m done” is generally never experienced. If the disease is not treated and the stricture reaches the point of complete closure, the condition we call “acute urinary retention,” in which the patient cannot urinate at all and must apply to the emergency department with severe abdominal pain, emerges. Worse still, the dirty urine constantly accumulating in the bladder may start a process in which infections reach the kidneys and in the following years progress to irreversible kidney failure.

Which Modern Tests Are Used in the Diagnosis of Urethral Stricture?

After patients describe their complaints and undergo a physical examination, some special tests are used to turn suspicions into objective data. The diagnostic process usually begins with painless and simple tests and progresses toward different imaging methods according to the severity of the condition.

As a first step, Uroflowmetry, or as it is popularly called, the “urine flow test,” is applied. The patient urinates into a special electronic device resembling a toilet while feeling the urge. This device measures how many milliliters of urine are expelled per second and draws a graph. While the graph of a normal healthy individual rises and falls rapidly in a bell shape, the urine flow graph of a patient with urethral stricture takes the shape of an almost flat “plateau.” In this test, a maximum urine flow rate (Qmax) below the level of 15 mL/sec raises a very strong suspicion of urethral stricture. Immediately afterwards, the amount of dirty urine remaining in the patient’s bladder after urination is checked with an ultrasound device; this amount is a very important indicator showing the functional health of the urinary bladder.

The most important radiological method to confirm the diagnosis and map the anatomy of the stricture is the contrast imaging called Retrograde Urethrography (RUG). A special contrast agent is gently given through the tip of the urinary canal and consecutive X-ray films are taken. The administered agent reveals exactly where the stricture begins, how long it is, and how narrow it has become, just like an X-ray mold. In complex strictures in the posterior region or in conditions involving the bladder neck, a different technique may be used in which the agent is filled directly into the bladder and films are taken while the patient urinates. Finally, in cases where suspicions continue or before planning surgery, the procedure called Urethroscopy is used in order to see the tissue with our own eyes. By entering the canal with very thin and flexible tubes with a light and camera at the tip, the surface structure of the stricture is directly examined on a television screen.

What Are the Non-Surgical or Closed Methods in the Treatment of Urethral Stricture?

There is no single standard approach in the treatment of this disease; the treatment decision depends entirely on the patient’s complaints, the location of the stricture in the urinary canal, its length, and how much the tissue has hardened.

Historically, one of the most commonly applied methods is the procedure called “urethral dilation,” that is, forcibly widening the urinary tract with thin metal or plastic tubes. Although this very short procedure may relieve the patient at that moment, unfortunately it certainly does not provide a definitive curative solution. On the contrary, the advancement of metal instruments by tearing the hard tissue inside the canal creates new and deeper bleeding in the tissue and causes the formation of a much longer, thicker, and more complex stricture tissue during the healing process.

As an alternative, the frequently applied “Closed Surgery” or, in medical language, Direct Vision Internal Urethrotomy (DVIU), is based on the principle of entering the canal with an instrument with a camera at the tip and opening the narrowed region by cutting it from the inside with a fine cold knife or special lasers (such as Holmium:YAG). The use of laser offers a higher success potential compared to traditional knives because it vaporizes the hardened scar tissue in that region. However, there is a very important golden rule here: for this procedure to be successful, the stricture must be shorter than 2 cm and the scar tissue must not have extended very deeply into the canal. According to statistics, the success rate of the first closed intervention that meets these suitable conditions varies between 30% and 70%. The long-term chance of success of making more than two closed incisions on the same stricture is close to zero. Unfortunately, as patients enter the cycle of “having it cut every three months,” the stricture segment becomes longer and makes it harder for the future chances of permanent treatments.

What Is the Drug-Coated Balloon (Optilume) Treatment Developed for Urethral Stricture?

One of the newest products of technological and medical research in the treatment of urethral stricture is the “Drug-Coated Balloon,” that is, Optilume technology, which combines closed mechanical procedures and the concept of drug treatment in the same pot. In strictures shorter than 3 cm that have been widened with closed methods but constantly tend to narrow again, it is a very strong alternative to protect the patient from major open surgery (urethroplasty) or postpone that process.

In this procedure, a special catheter with a deflated balloon at its tip is advanced to the area where the stricture is located. When inflated, the balloon cracks the hard and non-stretchable scar tissue inside the canal and restores the canal to its former diameter. The revolutionary part of the work is on the surface of the balloon. The outer surface of the balloon is coated with a special drug called Paclitaxel, which strongly suppresses cell division and the wound healing response. While the balloon inflates and cracks the tissue, with the effect of high pressure this drug passes directly into the inner layers of the tissue and seriously prevents that region from closing and narrowing again by stopping cell proliferation there. While at the end of one year only 21% of patients can continue to urinate successfully with classical widening methods, with the Optilume application this rate rises above 75% and a tremendous increase is achieved in urine flow rates.

How Is Urethroplasty Surgery, Which Offers a Definitive Solution for Urethral Stricture, Performed?

For patients in whom no result can be obtained with closed or widening methods or who present with very long strictures even at the first diagnosis, the only real solution is reconstructive (open) surgeries that we call “urethroplasty,” involving the repair or reshaping of the urinary canal. This is the most successful method accepted as the “gold standard” for these strictures worldwide. These surgeries require delicate surgical workmanship.

In cases where the stricture is around 2 cm and relatively shorter, the “Excision and End-to-End Reconnection” procedure is performed. With a small incision made through the perineum, the surgeon reaches the urinary canal. The problematic canal region, which is diseased, calcified, and hardened, is completely cut out like with a pair of scissors. The two remaining healthy and soft ends are widened and sewn together with extremely fine absorbable sutures. The most critical point of this surgery is that when the two ends are drawn together, there must absolutely be no tension. In suitable patients sutured in a tension-free manner, the lifelong success rate of this surgery is between 90% and 95%. If tension occurs between the ends, serious deformities such as penile curvature (chordee) may develop in the following years.

Why Is Oral Tissue (Buccal Mucosal Graft) Used in Urethral Stricture Surgery?

When the length of the stricture is too great (greater than 2 cm), it becomes impossible to completely remove the diseased tissue; because the remaining ends become so far apart that when sewn together they seriously shorten or bend the penis. At this point, the procedure of repairing the urinary canal just as if widening a tight garment by sewing an extra piece of fabric, namely “Augmentation Urethroplasty,” comes into play. Years of research have proven that the most perfect tissue in the human body that can be used as a patch for the urinary canal is the “oral mucosa.” The very important reasons why this tissue is intensely preferred in surgery are as follows:

• It does not contain hair
• It is naturally compatible with a moist environment
• It has a thick epithelium highly resistant to friction
• It is incredibly rich in blood vessels
• It has a very rapid healing potential
• It can be obtained easily

During the operation, a tissue patch (graft) of appropriate length is carefully taken from the inside of the patient’s cheek. Then, by finding the urinary canal through the perineum, the narrowed region is completely cut lengthwise and opened like a book. The oral patch obtained is placed into this slit in appropriate dimensions. Depending on the location of the stricture and the surgeon’s evaluation, this patch is fixed by sewing it with extremely fine sutures either to the upper surface (dorsal) or the lower surface (ventral) of the urinary canal. This patch, which is fully attached (quilted) to the healthy, well-vascularized tissues below or above it, begins to receive blood from its new region and over time becomes a permanent and healthy part of the urethral tissue, enlarging the diameter of the urinary canal so that it remains wide for life. Although patches taken from the foreskin or the skin of the leg were used in the past, oral tissue has become the absolute ruler of these surgeries because they are both cosmetically troublesome and carry the risk of hair growth or sacculation inside them.

How Are Cases of Urethral Stricture Due to Pelvic Traumas Managed?

Posterior urethral ruptures and strictures resulting from severe traumas such as traffic accidents, falls from height, and pelvic bone fractures are among the most complex areas of reconstructive urology. In these ruptures occurring just below the prostate, the two urethral ends break away from each other, separate, and the gap between them turns into a scar tissue as hard and large as bone with the clotting of bleeding. These patients may have to spend months with a permanent urinary catheter.

In the treatment of these patients, a special surgical algorithm (Elaborated Perineal Approach) applied by entering through the perineum and proceeding step by step is used. In order to close the large distance between them and sew the ends without tension, the surgeon applies four different techniques in sequence. First of all, the urinary canal is released as much as possible from above downward toward the penis, thus saving distance. If this is not enough, the spongy tissues on both sides of the penis are separated from each other to obtain additional distance. If the distance is still far, a small piece of bone is carved from the lower part of the pelvis (pubis) so that the canal can pass through a shorter route. And if necessary, in the final stage, the urethra is diverted completely in another direction and advanced directly toward the prostate through a shortened route. Although it sounds very frightening at first, thanks to this staged approach, even in ruptures 3–4 cm long in the bone region, an extremely successful, permanent, and functional repair with a success rate above 90% can be performed.

How Does the Recovery Process Progress After Urethral Stricture Surgeries?

After urethral surgeries, the process the patient will spend in bed and be monitored is at least as important as the surgery itself. Patients are kept in the hospital for about 1–3 days according to the type of surgery. On the operating table, a soft catheter made of special silicone is inserted so that the newly created structure in the urinary canal is not damaged and urine can be expelled without touching that suture area.

The duration this catheter remains in place differs according to the type of treatment. While a period of 10 days is usually sufficient in closed surgeries, in urethroplasty surgeries where the tissues are completely reconstructed, it is mandatory for the catheter to remain for a period such as 3 weeks for the sutures to heal. Immediately before removing the catheter, a leakage check is definitely performed with an X-ray film taken by administering contrast around the urinary tract. When healing is completed, the catheter is removed and the patient starts to urinate normally. The follow-up process is monitored in detail both with objective figures and with the patient’s complaint forms.

• 3rd Month Check-up: Urine flow test (Qmax > 15) and measurement of the amount of urine remaining in the bladder on ultrasound.
• 6th Month Check-up: Checking whether there is a decrease in urine flow rate and symptom questioning (IPSS test).
• 12th Month Check-up: Flow test, and if there is a suspicious condition, radiological X-ray examination to see the scar tissue.

Do Urethral Stricture Treatments Affect Sexual Life and Reproduction?

In male anatomy, reproduction, sexual functions, and the urinary tract are physiologically very closely interconnected. Because the urinary canal (urethra) is in very close proximity to the spongy structures (corpus cavernosum) that enable erection of the penis and to the special nerve bundles that manage erection, the most common question from patients before surgery is the effect of these procedures on sexual health.

Especially after urethroplasty surgeries requiring major and deep tissue dissection, experiencing temporary erection problems due to the effect of surgical trauma is quite an expected situation. However, in well-applied techniques, permanent nerve or vascular damage is rare, and this condition generally resolves spontaneously within an average of 6 months as the patient’s tissue heals. Recovery is much faster in traumas or surgeries experienced at a younger age.

As for semen (ejaculation) discharge, a permanent change may be experienced. Since the muscle group (bulbospongiosus) located in the outer part of the urinary canal and enabling the semen to be expelled outward with force is necessarily cut during surgery to reach the stricture and its anatomy is disrupted, patients may complain after the procedure that their semen does not come out as forcefully as before. Sometimes semen may even accumulate in the canal to some extent and come as leakage together with urine in the toilet. In patients from whom oral tissue is taken, numbness or pain may occur inside the mouth, but since this is one of the fastest-healing tissues in the body, within a few weeks no scar or long-term eating and drinking difficulty remains in the donor area.